Loading

By K. Agenak. University of the Virgin Islands.

Consolidation treatment buy viagra soft 100mg overnight delivery, aimed at further reducing residual leukemia purchase viagra soft 50mg on-line, delivers multiple chemotherapies in a relatively short period of time buy discount viagra soft 50mg on-line. Maintenance therapy with methotrexate and 6-mercaptopurine, vincristine, and prednisone is given for 2 to 3 years to prevent relapse; therapy is discontinued for children who remain in complete remission for 2 to 3 years. Patients with greater than 25% blasts after induction chemother- apy or greater than 5% blasts after consolidation chemotherapy have a high risk of relapse. Therefore, allogeneic hematopoietic stem cell transplantation is recom- mended after the first complete remission in this patient population. The hematologic finding of sickle cell disease (Case 13) typically is isolated to the red blood cell while that of leuke- mia affects all cell lines. The school will not allow the child to reg- ister until his immunizations are up-to-date. Call the school nurse or principal to inform him or her that this child should not receive immunizations while he is taking chemotherapy. Call the school nurse or principal to inform him or her that this child will never receive immunizations because of the alteration in his immune system. Laboratory testing reveals a normal hemoglobin, hematocrit, and white blood cell count and differential. A high susceptibility to leukemia is associated with certain heritable dis- eases (Klinefelter syndrome, Bloom syndrome, Fanconi syndrome, ataxia tel- angiectasia, neurofibromatosis) and chromosomal disorders such as Down syndrome. Children with Down syndrome have a 10- to 15-fold increased risk for developing leukemia and should have routine screening performed at well-child checks. Although the viruses in the vaccine are attenu- ated, immunosuppression from treatment can be profound and viral disease can result. Immunizations without live virus (diphtheria, tetanus, inactivated poliovirus vaccine, hepatitis A and B) are not absolutely contraindicated in this case, but the immunosuppression with chemotherapy often inhibits anti- body responses. The platelet count frequently is less than 20,000/mm3, but other laboratory test results are normal, including the bone marrow aspiration (which may show an increase in megakaryocytes). She reports he developed nasal congestion and sore throat 24 hours prior, then a cough a few hours previously. Over the past 2 hours, he has complained of chest pain and has been breathing rapidly. His mother adminis- tered a unit dose of albuterol via the nebulizer and then a second dose 5 minutes later. Your examination reveals an afebrile man with a respiratory rate of 40 breaths/minute, oxygen saturation of 88% by pulse oximetry, and a heart rate of 130 beats/min. His blood pressure is normal, but his capillary refill is sluggish at 4 to 6 seconds. Intravenous administration of fluids and medications is indicated for a patient with this degree of distress. Know how to classify asthma severity and give the management of each level (Table 20–1). Less likely conditions include anaphylaxis, cystic fibrosis, foreign-body aspiration, and congestive heart failure. His drowsiness is of particular concern, indicat- ing impending respiratory failure; his respiratory and circulatory status must be assessed frequently. The paucity of wheezes results from severe airway obstruction and reduced air movement; wheezing is likely to increase when therapy allows more air movement. A variance of greater than 10 mm Hg between inspiration and expiration suggests severe obstructive airway disease, pericardial tamponade, or constrictive pericarditis. For patients with asthma, this test demonstrates airflow obstruction and reversibility, and can be used to determine an individual’s response to treatment. The median age at onset is 4 years, but 20% of children develop symptoms within the first year of life. More than half of children with asthma have symptom resolution by young adulthood. Heavy exposure to pollution, aller- gens, or cigarette smoke makes resolution less likely. An immediate immunoglobulin (Ig) E response to environmental triggers occurs within 15 to 30 minutes and includes vasodilation, increased vascular permeability, smooth-muscle constriction, and mucus secretion. Symptoms result from these changes and may include wheezing, cough (especially if worse at night), difficulty breathing, or chest tightness. These symptoms will be triggered by dust mites, animal dander, cigarette smoke, pollution, weather changes, pollen, upper respiratory infections, or exercise (particularly when performed in a cold environment). The presence of other atopic diseases such as allergic rhinitis, nasal polyps, or atopic dermatitis, may be supportive of the diagnosis. Spirometry should be performed, if possible, whenever a diagnosis of asthma is considered. A chest radiograph is not a required study but can help exclude other diagnoses such as congestive heart failure or in toddlers, foreign-body aspiration. Nonspecific findings of hyperinflation, flattened diaphragms, or increased bron- chial wall markings may be the only abnormalities seen with asthma. Other tests such as sweat chloride testing may be needed to exclude other obstructive diseases of the small airways, such as cystic fibrosis. Viral bronchiolitis is the most com- monly occurring disease of the small airways and usually does not respond to con- ventional asthma therapy. Asthma management involves classifying the baseline disease severity and identi- fying and minimizing exposure to triggers. Classification is made based on spirom- etry and the patient’s symptoms over prior 2 to 4 weeks. The features that are assessed are the frequency of nighttime symptoms, how often the rescue medica- tion is needed, and how much symptoms limit daily activities. Severity is defined as either intermittent or persistent; persistent asthma is further divided into mild, moderate, or severe. Pharmacotherapy for asthma includes quick-relief medications for the acute symptoms and exacerbations, as well as long-term controller medications. These agents also can be used immediately prior to exercise or exposure to allergens to minimize the acute asthmatic response. Increased levels of drug are delivered to the lungs and toxicity is decreased when these medications are delivered through inhalation routes (nebulizer or inhaler). When inhalers are used, a reservoir device (“spacer”) is used to maximize the amount of medication delivered to the lungs. Patients must not over-rely on short-acting inhalers because this practice is associ- ated with death in severe asthma attacks. The most potent available anti-inflammatory drugs are corticosteroids, which are useful for acute exacerbations (oral or intravenous prednisone, prednisolone) and for chronic therapy (inhaled corticosteroids). The inhaled route is best for chronic therapy so that adverse effects on bone mineral density, growth, and immune function are minimized while maximal amounts of the drug can be delivered to the lungs.

The resultant abstinence syndrome is mild 50mg viagra soft visa, with symptoms resembling those of moderate influenza buy viagra soft 50mg on line. When substituting methadone for another opioid order cheapest viagra soft and viagra soft, suppression of the abstinence syndrome requires that methadone dosage be closely matched to the existing degree of physical dependence. Hence, to ensure that methadone dosing is adequate, the extent of physical dependence must be assessed. This can be accomplished by taking a history on the extent of drug use and by observing the patient for symptoms of withdrawal. Because information from addicts is not likely to permit accurate assessment of dependence, it is essential to observe the patient to make certain methadone dosage is sufficient to suppress withdrawal. Uses of methadone for maintenance therapy and suppressive therapy are discussed separately later. Because of the long half-life of methadone, it should only be prescribed by health care providers with special training in chronic pain management. Like methadone, buprenorphine can be substituted for the opioid on which an addict is physically dependent and can thereby prevent symptoms of withdrawal. After the addict is stabilized on buprenorphine, the dosage is gradually reduced, thereby keeping symptoms of withdrawal to a minimum. Clonidine-Assisted Withdrawal Clonidine is a centrally acting alpha -adrenergic agonist. When2 administered to an individual physically dependent on opioids, clonidine can suppress some symptoms of abstinence. Clonidine is most effective against symptoms related to autonomic hyperactivity (nausea, vomiting, diarrhea). Drugs for Long-Term Management of Opioid Addiction Three kinds of drugs are employed for long-term management: opioid agonists, opioid agonist-antagonists, and opioid antagonists. Opioid agonists (methadone) and agonist-antagonists (buprenorphine) substitute for the abused opioid and are given to patients who are not yet ready for detoxification. In contrast, opioid antagonists (naltrexone) are used to discourage renewed opioid use after detoxification has been accomplished. Methadone In addition to its role in facilitating opioid withdrawal, methadone [Methadose, Diskets] can be used for maintenance therapy and suppressive therapy. These strategies are employed to modify drug-using behavior in addicts who are not ready to try withdrawal. Methadone maintenance consists of transferring the addict from the abused opioid to oral methadone. By taking methadone, the addict avoids both withdrawal and the need to procure illegal drugs. Maintenance is most effective when done in conjunction with nondrug measures directed at altering patterns of drug use. Suppressive therapy is done to prevent the reinforcing effects of opioid- induced euphoria. Suppression is achieved by giving the addict progressively larger doses of methadone until a very high dose (120 mg/day) is reached. Building up to this dose creates a high degree of tolerance, and hence no subjective effects are experienced from the methadone itself. Because cross- tolerance exists among opioids, after the patient is tolerant to methadone, taking street drugs, even in high doses, cannot produce significant desirable effects. As a result, individuals made tolerant with methadone will be less likely to seek out illicit opioids. Use of methadone to treat opioid addicts is restricted to opioid treatment programs approved by the designated state authority and certified by the federal Substance Abuse and Mental Health Services Administration. Buprenorphine Buprenorphine [Subutex, Suboxone, Bunavail] is an agonist-antagonist opioid. The drug is a partial agonist at mu receptors and a full antagonist at kappa receptors. Buprenorphine can be used for maintenance therapy and to facilitate detoxification (see earlier). When used for maintenance, buprenorphine alleviates craving, reduces use of illicit opioids, and increases retention in therapeutic programs. Unlike methadone, which is available only through certified opioid treatment programs, buprenorphine can be prescribed and dispensed in general medical settings, such as primary care offices. Prescribers must receive at least 8 hours of authorized training and must register with the Substance Abuse and Mental Health Services Administration. Buprenorphine has several properties that make it attractive for treating addiction. Because it is a partial agonist at mu receptors, it has a low potential for abuse—but can still suppress craving for opioids. If the dosage is sufficiently high, buprenorphine can completely block access of strong opioids to mu receptors and can thereby prevent opioid-induced euphoria. With buprenorphine, there is a ceiling to respiratory depression, which makes it safer than methadone. Development of physical dependence is low, and hence withdrawal is relatively mild. Buprenorphine is currently available in four formulations that are dosed once a day. One formulation—sublingual tablets marketed as Subutex—contains buprenorphine alone. The other three formulations—sublingual tablets, sublingual films, and buccal film, marketed as Suboxone and Bunavail—contain buprenorphine combined with naloxone. Subutex is used for the first few days of treatment, and then Suboxone is used for long-term maintenance. The newest film, Bunavail, is placed on the inside of each cheek and is used for long-term maintenance. However, with sublingual administration, very little naloxone is absorbed, and hence, when the drug is administered as intended, the risk for withdrawal is low. Nonetheless, because there is a small risk with sublingual Suboxone, treatment is initiated with Subutex, thereby allowing substitution of buprenorphine for the abused opioid. Naltrexone After a patient has undergone opioid detoxification, naltrexone [ReVia, Vivitrol], a pure opioid antagonist, can be used to discourage renewed opioid abuse. By preventing pleasurable effects, naltrexone eliminates the reinforcing properties of opioid use. When the former addict learns that taking an opioid cannot produce the desired response, drug-using behavior will cease. Naltrexone is not a controlled substance, and hence prescribers require no special training or certification. At this time, Vivitrol is the only long-acting drug for managing opioid addiction. With the exception of the benzodiazepines, all of these drugs are more alike than different.

To avoid frther self-inficted harm purchase viagra soft with a visa, his agitation and pain must be immediately addressed buy 50 mg viagra soft with amex. The patient has experienced head trauma and subsequently a rapid onset/ofset agent that will permit reassessment of his neurological status would be optimal order viagra soft 50 mg amex. Agitation, anxiety, and pain can bring about many adverse side efects including increased endogenous catecholamine activity, myo­ cardial ischemia, hypercoagulable and hypermetabolic states, sleep deprivation, and delirium possibly resulting in self-injury via removal of life-sustaining devices. Although such adverse efects should be actively avoided, the care providers must be mindfl of the potential detrimental efects associated with pharmacological treat­ ment of pain and agitation. When considering sedation and pain management, the anticipated duration of treatment and mechanical ventilation should be considered. Addressing the target of intervention will help determine the most practical medication strategies. Very often, a combination of opioids and benzodiazepines are used for analgesia and sedation. Pain is common, and the majority ofalgorithms incorporate testing for pain, with patient self-report being the most accurate means of assessment if the patient is able to communicate. Notably, the validity of these scales declines with the increased depth of sedation. In the absence of organic or natural causes of obtundation (ie, central nervous system pathology), a Ramsay score of 5 or 6 represents oversedation. Once a patient is started on a sedative and analgesic medication, the goal should be to minimize the risk of continued infsion of these agents. Both sedative and analgesic agents should be interrupted once daily, unless there is evidence for ongoing patient distress. A bolus should be given to de-escalate symptoms and restart both sedative and analgesic drugs at halfthe previous infsion doses with subsequent titration. Selection of Pharmacologic Therapy In agitated and anxious patients, the clinician can frst attempt nonpharmacologic interventions such as comfortable positioning, verbal reassurance, and encourag­ ing the presence of family and friends, though such interventions are often inad­ equate alone and ultimately require medical intervention. Because the patient is awake, we can ask him directly about pain, instructing him to quantif his pain numerically if he is able to do so. The patient dis­ cussed earlier has experienced head trauma for which frequent neurologic exami­ nations may be necessary in the immediate observation period. In this situation, propofol may be the best choice given its rapid onset and ofset. Midazolam (Versed) can also be used as a sedative in this patient, although its ofset is longer than propo­ fol and frequent neurologic examinations would not be as easy to administer. As such, it is important to communicate the sedation goals with the entire health-care team. These drugs are also very good at palliating coughing and the subjective sense of dyspnea-particularly important for patients who are mechanically ventilated. Among the opioids, fen­ tanylhas a rapid onset of action (1 minute) and rapidly redistributes into peripheral tissues, resulting in a short half-life (0. If the patient is easily awakened, we can address pain by simply asking the patient to quantif the pain. If the patient is not easily awakened, tools such as facial expression, body movement, and ventilator synchrony can be utilized, again with the bedside nurse being the most important person in this assessment. After initiation of sedation and analgesia, it is important to continuously reevaluate the clinical status. Sedation and Analgesic Selection fo r the Mechanically Ve ntilated Patients Patients in need of mechanical ventilation generally require sedation and/or anal­ gesic medication to overcome the stress and discomfort associated with ventilation. As patients who require prolonged ventilatory support progress toward extubation, sedation and analgesic agents are generally decreased. Medication tapering at this time must be done in a way to avoid withdrawal symptoms, avoid over-sedation, and provide adequate comfort so that the patient is able to cooperate with the transi­ tional process. When alcohol consumption stops in an individual with a chronic consumption history, the combination of excess excitatory activities and the withdrawal of inhibitory activities can cause symp­ toms of withdrawal, which include a number of neuropsychiatric and hemodynamic manifestations. Alcohol withdrawal symptoms may include tremulousness (onset within hours, peak 10-30 hours, subsides at approximately 40 hours), seizures (onset 6-48 hours, peak 13-24 hours), hallucination (onset 8-48 hours, may persist 1-6 days), and delirium tremens (onset 48-96 hours). Recognition of patients at risk for alcohol withdrawal is important and can be determined based on social his­ tory and history of withdrawal episodes. Chronic ingestion and the administration of exogenous opioids lead to dimin­ ished endogenous opioid peptides, therefore when exogenous opioids are abruptly discontinued, the patients may develop withdrawal symptoms. Early symptoms of opioid withdrawal may include yawning, rhinorrhea, sneezing, and seating. Later manifestation of withdrawal may include restlessness, irritability, tachycardia, tremor, hyperthermia, vomiting, and muscle spasm. Withdrawal symptoms may begin within 6 to 12 hours after the last dose of short-acting opioid or after 36 to 48 hours of the last dose of long-acting opioids such as methadone. Withdrawal can occur when long-term administration of opioids is discontinued or tapered too rapidly. Patients receiving higher doses of the medications for prolonged periods of time ( >7 days) have increased susceptibility for developing withdrawal. Administer a second analgesic as dificulty in ventilating her and agitation are secondary to poorly controlled pain. Propofol infsion syndrome is a rare but serious and potentiallyfatal adverse efect, typically seen with infsion rates >83 lgfkg/min for more than 48 hours and carries with it a mortality rate of up to 85%. This syndrome is charac­ terized by dysarrhythmias, heart failure, metabolic acidosis, hyperkalemia, and rhabdomyolysis. High-risk patients include those receiving high doses of the drug, those with history of hypertriglyceridemia, and those concurrently receiving parenteral lipids for nutrition. Treatment consists of immediate ces­ sation of propofol infsion and then correction of hemodynamic and meta­ bolic abnormalities. Some patients mayremaindelirious, agitated, andhave difculty maintain­ ing ventilation regardless of whether they are on an efective dose of anxio­ lytic drugs. Ifthe patient is tracheally intubated, mechanically ventilated, and receiving adequate sedation, using a neuromuscular blockade to paralyze the patient is a good option. Fentanyl is metabolized by the liver which creates inactive metabolites that are excreted by the kidneys. Because the metabolites are inactive, fentanyl a good choice for patients with renal insuficiency. Morphine is conjugated by the liver to metabolites that include morphine-6-glucuronide, a potent metabo­ lite. Both morphine and morphine-6-glucuronide are eliminated by thekidney, thus patients with renal dysfunction may sufer from prolonged drug efects. What are post-resuscitation treatment strategies that have shown to improve outcome? Other strat­ egies that have shown to improve neurologic outcome in post-cardiac arrest patients include controlled reoxygenation, therapeutic hypothermia, and glu­ cose management. To learn the post-cardiac arrest syndrome and strategies directed toward its management, including optimization of neurological outcome, optimization of myocardial fnction, glucose management, and controlled reoxygenation.

Because griseofulvin is present buy cheap viagra soft 100 mg online, newly formed keratin is resistant to fungal invasion order 50mg viagra soft overnight delivery. Griseofulvin kills fungi by inhibiting fungal mitosis by binding to components of microtubules purchase viagra soft 50 mg, the structures that form the mitotic spindle. Because griseofulvin acts by disrupting mitosis, the drug only affects fungi that are actively growing. Pharmacokinetics Administration is oral, and absorption can be enhanced by dosing with a fatty meal. As noted, griseofulvin is deposited in the keratin precursor cells of skin, hair, and nails. Therapeutic Uses Griseofulvin is employed orally to treat dermatophytic infections of the skin, hair, and nails. The drug is not active against Candida species, nor is it useful against systemic mycoses. However, infections of the palms may require 2 to 3 months of treatment, and a year or more may be needed to eliminate infections of the toenails. Griseofulvin may cause hepatotoxicity and photosensitivity in patients with porphyria. The drug is contraindicated for individuals with a history of porphyria or hepatocellular disease. Drug Interactions Griseofulvin induces hepatic drug-metabolizing enzymes and can decrease the effects of warfarin. Griseofulvin is formulated in a solution (125 mg/5 mL) and in two particle sizes: microsized and ultramicrosized. With microsized formulations, the usual adult dosage is 500 mg to 1 g/day, and the usual pediatric dosage is 11 mg/kg/day. The ultramicrosized particles are better absorbed than the microsized particles, and hence doses of ultramicrocrystalline griseofulvin are about 30% lower than doses of microcrystalline griseofulvin. Polyene Antibiotics Nystatin Actions, Uses, and Adverse Effects Nystatin [Mycostatin, Nyaderm ] is a polyene antibiotic used only for candidiasis. Nystatin is the drug of choice for intestinal candidiasis and is also employed to treat candidal infections of the skin, mouth, esophagus, and vagina. Preparations, Dosage, and Administration For oral administration, nystatin is supplied as a suspension and in tablets and lozenges; dosages range from 400,000 to 1 million units 3 to 4 times a day. Vaginal tablets are employed for vaginal candidiasis; the usual dosage is 100,000 units once a day for 2 weeks. Nystatin is supplied as a cream, ointment, and powder to treat candidiasis of the skin. The cream and ointment formulations are applied twice daily; the powder is applied 3 times daily. Although approved only for topical treatment of dermatophytic infections, naftifine is active against a broad spectrum of pathogenic fungi. The drug works by inhibiting squalene epoxidase, thus inhibiting synthesis of ergosterol, a key component of the fungal cell membrane. Terbinafine Actions and Uses Terbinafine [Lamisil] belongs to the same chemical family as naftifine and has the same mechanism of action: inhibition of squalene epoxidase with resultant inhibition of ergosterol synthesis. The drug is highly active against dermatophytes and less active against Candida species. Oral therapy is used for ringworm and onychomycosis (fungal infection of the nails). The most common side effects are headache, diarrhea, dyspepsia, and abdominal pain. Some terbinafine users have died of liver failure, and others have required a liver transplantation. In addition, patients should be informed about signs of liver dysfunction (persistent nausea, anorexia, fatigue, vomiting, jaundice, right upper abdominal pain, dark urine, pale stools) and, if they appear, should discontinue terbinafine immediately and undergo evaluation of liver function. Preparations, Dosage, and Administration Terbinafine for oral therapy is available in tablets (250 mg). The oral dosage for nail infections is 250 mg/day for 6 to 12 weeks, and the dosage for ringworm is 250 mg/day for 2 to 6 weeks. Terbinafine for topical therapy is available as a gel, spray, powder, and cream, all with strength of 1%. Butenafine Butenafine [Lotrimin Ultra Cream, Mentax] is chemically similar to naftifine and terbinafine, although butenafine is not a true allylamine. However, it does have the same mechanism of action: inhibition of squalene epoxidase with resultant inhibition of ergosterol synthesis. Butenafine is indicated for topical therapy of tinea pedis, tinea corporis, tinea cruris, and tinea versicolor. Other Drugs for Superficial Mycoses Tolnaftate Tolnaftate [Tinactin, others] is employed topically to treat a variety of superficial mycoses. Undecylenic Acid Undecylenic acid [Fungi-Nail, others] is a topical agent used to treat superficial mycoses. Ciclopirox Ciclopirox [Loprox, Penlac Nail Lacquer] is a broad-spectrum, topical antifungal drug. Benefits derive from chelating iron and aluminum present in metal- dependent enzymes that protect fungi from peroxides. Ciclopirox is used for infections of the skin (discussed here) and for infections of the fingernails and toenails (discussed earlier in the section “Onychomycosis”). When applied to the skin, ciclopirox is active against dermatophytes and Candida species. The drug is effective against superficial candidiasis and tinea pedis, tinea cruris, and tinea corporis. Ciclopirox penetrates the epidermis to the dermis, but systemic absorption is minimum, and hence no significant systemic accumulation occurs. For treatment of skin infections, ciclopirox is available as a 1% shampoo and as a 0. Although antiviral therapy has made significant advances, our ability to treat viral infections remains limited. Compared with the dramatic advances made in antibacterial therapy over the past half-century, efforts to develop safe and effective antiviral drugs have been less successful. A major reason for this lack of success resides in the process of viral replication: viruses are obligate intracellular parasites that use the biochemical machinery of host cells to reproduce. Because the viral growth cycle employs host-cell enzymes and substrates, it is difficult to suppress viral replication without doing significant harm to the host. The antiviral drugs used clinically act by suppressing biochemical processes unique to viral reproduction. As our knowledge of viral molecular biology expands, additional virus-specific processes will be discovered, giving us new targets for drugs. Both conditions are discussed in Chapter 53, along with the vaccine used to prevent chickenpox.

Leave a comment

Your email address will not be published. Required fields are marked *